New York State Correctional Officers and Police ... - The Standard

The Standard Life Insurance Company of New York

800.378.4668 Tel 800.331.3397 Fax

Administrative Office: 900 SW Fifth Avenue Portland OR 97204

New York State Correctional Officers and

Police Benevolent Association

Notice of Option to Continue

Group Life Insurance/Portability

Of Insurance Application

INSTRUCTIONS - PLEASE READ CAREFULLY

Portability Of Insurance Notice

You may continue your Life Insurance and other insurance eligible for portability as shown in your Certificate if your employment

with the Employer terminates, subject to the following:

1.

The amount of any Insurance to be continued must have been continuously in effect for at least 3 consecutive months

on the date your employment terminates.

2.

Termination of your employment is not due to your retirement.

3.

If you do not continue your Life Insurance, you may not continue any other Insurance.

The minimum and maximum amounts of Insurance eligible for Portability Of Insurance are shown in your Certificate. The

amounts of Insurance you continue cannot be increased. Insurance amounts will be reduced or terminated according to the

terms of the Group Policy in effect on the date your employment terminates.

The maximum amount of Life Insurance you may continue is the lesser of: (1) the amount in effect on the date your employment

terminates; or (2) $300,000. The minimum amount of Life Insurance you may continue is $25,000.

NOTE: Refer to Right To Convert in your Certificate for information regarding eligibility to convert to an individual life

insurance policy. The amount of Insurance you continue will be reduced by any amount of Insurance you convert.

How To Apply

You must apply in writing and pay the first premium to us within 31 days after the date your employment terminates. This

packet has two pages and questions on these forms must be completed. If you have questions, please contact our office at

the phone number shown above. You are responsible for making sure all required forms are completed and returned to our

office. Processing will begin when completed forms are received by us.

Premium rates are shown in your Certificate, and are subject to increase with advancing age. Premium rates may be changed

by The Standard Life Insurance Company of New York with advance written notice. If approved, you will be billed quarterly

(every three months), at your home address. Premium must be received by the due date. There is no grace period for Portability

Of Insurance. Checks are to be payable to The Standard Life Insurance Company of New York.

Keep your Certificate. It is your certificate of coverage for your continued insurance under the Portability Of Insurance provision.

Please note that Insurance continued under the Portability Of Insurance provision ends automatically on the earliest of:

1.

The date it would otherwise end under the Group Policy.

2.

The date you become insured under any other group life insurance plan.

3.

For any Dependent, the date you insure the Dependent under any other group life insurance plan.

Beneficiary Designation

Please provide us with the beneficiary designation form on file with the Policyholder. If you cannot provide that

form, or if you wish to change your beneficiary designation, please complete the Beneficiary section on Page 3. If we do not

receive the form and if you do not complete the Beneficiary section on Page 3, you will not have a designated beneficiary. In

that event, payment of any benefit will be made in accordance with the Beneficiary Provisions of the Group Policy.

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The Standard Life Insurance Company of New York

New York State Correctional Officers and

Police Benevolent Association

Group Life Insurance Portability Application

800.378.4668 Tel 800.331.3397 Fax

Administrative Office: 900 SW Fifth Avenue Portland OR 97204

Please type or print. Complete entire form.

IDENTIFICATION

Name of Proposed Insured: (last, first, middle)

Street Address:

City:

State:

Social Security Number:

Telephone:

Birthdate:

Sex:

Spouse Name:

Birthdate:

Zip Code:

Male

Female

Social Security Number:

GROUP POLICY

Name of Policyholder:

Name of Employer, if different:

New York State Correctional Officers and Police Benevolent Association

Group Policy No.:

645228

Your occupation with the Policyholder:

? Date you last worked for the Policyholder:

? Employment termination date (if different):

Are you currently unable to work because of sickness or injury?

Yes

No

If yes, please contact your employer to determine eligibility for disability or waiver of premium benefits.

If date you last worked and employment termination date differ, please explain:

Date Notice of Option to Continue Your Insurance Under Portability Of Insurance was given:

/

/

ELIGIBILITY

Date you became insured under the Group Policy:

/

/

Has the amount of Insurance you wish to continue been continuously in effect for at least 3 consecutive months?

Spouse

Yes

No

Is your employment terminating because of retirement?

Yes

No

Are you planning to pursue other employment?

Yes

No

Employee

Yes

No

Children

Yes

No

AMOUNT

You may only continue amounts of Insurance that have been continuously in effect for at least 3 consecutive months

on the date your employment terminates. If you do not continue your Life Insurance, you may not continue any other insurance

that may be eligible for portability under the Group Policy. Accidental Death and Dismemberment (AD&D) Insurance may not be

continued The maximum amount of Life Insurance you may continue is the lesser of: (1) the amount in effect on the date your

employment terminates; or (2) $300,000. The minimum amount of Life Insurance you may continue is $25,000.

LIFE INSURANCE

OTHER:____________________________

Employee:

Spouse:

PLAN 1 (BASIC)

$_______________________

$_______________________

Each Child:

$_______________________

PLAN 2 (ADDITIONAL)

$_________________________

$_________________________

$__________________________________

$__________________________________

Billing: If approved, you will be billed quarterly (every three months), at your home address. Premium must be received

by the due date. There is no grace period for Portability Of Insurance.

(continued)

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The Standard Life Insurance Company of New York

800.378.4668 Tel 800.331.3397 Fax

900 SW Fifth Avenue Portland OR 97204

New York State Correctional Officers and

Police Benevolent Association

Beneficiary Designation and Agreement

BENEFICIARY

This beneficiary designation: (1) revokes all prior designations, and (2) applies to basic and additional insurance, if any, on your life

that you continue under the Portability Of Insurance provision. A separate designation must be completed for Supplemental Life

Insurance, if any. Insurance on your Spouse or other Dependents, if any, is payable to you, if living, or as provided under the terms

of the Group Policy.

?

Benefits are only payable to a contingent Beneficiary if you are not survived by one or more primary Beneficiary(ies).

?

If you name two or more Beneficiaries in a class:

1.

Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares.

2.

If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay each

surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise

due to any deceased Beneficiary(ies) to the surviving Beneficiaries pro rata based on the relationship that the designated

percentage or fractional share of each surviving Beneficiary bears to the total shares of all surviving Beneficiaries.

3.

If only one Beneficiary in a class survives, we will pay the total death benefits to that Beneficiary.

Primary ¨C Full Name

Contingent ¨C Full Name

Address

Address

Birth Date

Birth Date

Phone No.

Soc. Sec. No.

if known

% of Benefit

Total must

Relationship equal 100%

Phone No.

Soc. Sec. No.

if known

% of Benefit

Total must

Relationship equal 100%

AGREEMENT

I hereby apply to continue Insurance available under the terms of the Group Policy.

I agree that no coverage will take effect until it is approved in writing by The Standard Life Insurance Company of New York. I understand

that if my request is not accepted, any premium advanced by me will be refunded.

I understand that if I do not provide the beneficiary designation form on file with the Policyholder, or if I do not designate a beneficiary in

the Beneficiary section above, payment of any benefit will be made in accordance with the Beneficiary Provisions of the Group Policy.

I hereby represent that all statements contained herein are complete and true to the best of my knowledge and belief, and that I

meet all eligibility requirements for continued insurance under the Group Policy¡¯s Portability Of Insurance provision. I have read and

understand the information herein.

Signature:____________________________________________________________________________________________________________

Dated__________________________________________________

Print and Sign

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